Management of chronic stable angina: medical therapy, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft surgery. Lessons from the randomized trials.
OBJECTIVE
To review the available data on the treatment of chronic stable angina and formulate a rational approach to the use of pharmacologic therapy, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft surgery (CABG).


METHODS
A MEDLINE search of English-language literature published between 1976 and 1996 and the bibliographies of relevant articles.


METHODS
Primary research articles, meta-analyses, and meeting abstracts related to the management of chronic stable angina with an emphasis on comparisons of medical therapy, PTCA, and CABG.


METHODS
Three trials comparing medical therapy with PTCA, seven trials comparing medical therapy with CABG, and nine trials comparing PTCA with CABG.


RESULTS
Low-risk patients with single-vessel coronary artery disease and normal left ventricular function had greater alleviation of symptoms with PTCA than with medical treatment; mortality rates and rates of myocardial infarction were unchanged. In high-risk patients (risk was defined by severity of ischemia, number of diseased vessels, and presence of left ventricular dysfunction), improvement of survival was greater with CABG than with medical therapy. In moderate-risk patients with multivessel coronary artery disease (most had two-vessel disease and normal left ventricular function), PTCA and CABG produced equivalent mortality rates and rates of myocardial infarction.


CONCLUSIONS
In low-risk patients, a strategy of initial medical therapy is reasonable. In moderate-risk patients, PTCA and CABG produce similar mortality rates and rates of myocardial infarction but PTCA-treated patients require more revascularization procedures. In high-risk patients, CABG is usually preferred.
Solomon
A J
AJ
Georgetown University Medical Center, Division of Cardiology, Washington, DC 20007, USA.
Gersh
B J
BJ
D000787:Angina Pectoris / Q000150:complications / Q000188:drug therapy / Q000628:therapy*; D015906:Angioplasty, Balloon, Coronary; D002908:Chronic Disease; D001026:Coronary Artery Bypass; D006801:Humans; D009203:Myocardial Infarction / Q000150:complications / Q000401:mortality; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors